_____( Date )_____

ARACELI C. PASTOR, CESO V

Schools Division Superintendent
Schools Division Office of Ilocos Norte
Laoag City

Attention: ATTY. MARSHALL ELLIS M. DIEGO

INCIDENT REPORT

Madam:

This is in relation to the alleged (specific act/s of the Name of Student,

Teacher and/or Principal. Nota Bene: it is not important to allege the law that
has been violated), (Position/Grade of the Student, Teacher and/or Principal
involved), (Name of the school).

(Body and/or Narration of facts. The following should be answered in

the Body and/or Narration of facts: to wit

a. When did the Student, Teacher and/or Principal committed the

alleged act;

b. Where did the Student, Teacher and/or Principal committed the

alleged act;

c. What act/s did the Student, Teacher and/or Principal commit;

d. Who are involved in the incident, include if necessary, the witnesses

to the said incident. For future reference; and

e. How did the Student, Teacher and/or Principal commit the alleged
act/s.)

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 Attached herewith are the documents and/or name of the person/s
involved:

1. Written Complaint (It must be signed and dated) and/or Affidavit/s

of Complainant/s (complainants maybe the child involved or the
parent/s and/or guardian/s;

2. Written Statement (It must be signed and dated) and/or Affidavit/s

of witnesses;

3. Please include also the Contact Details and Addresses of the

Student, Teacher, Principal, Witnesses, and/or Parent/s or
Guardian/s;

4. Other related documentary and testimonial evidence (please specify),

if there are any.

For your information, as well as recommendation of whatever the

appropriate action that will be taken in the future.

Thank you and God bless.

Very truly yours,

SIGNATURE OVER PRINTED NAME

(Prinipal/Head Teacher/
Teacher/Parent/Guardian
and/or concerned citizen)

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